Caffeine Intoxication

An Analysis of Published Case Reports, 1883–2023

Background: Many case reports of acute caffeine intoxication have been published, but there have been hardly any systematic data analyses, nor have there been any prospective studies, representative epidemiologic studies, or guideline recommendations. In this review, we aim to describe the clinical entity of acute caffeine intoxication and its treatments to date on the basis of published case reports.

Methods: This review is based on pertinent case reports retrieved by a search in the PubMed, Google Scholar, and Semantic Scholar databases covering the period 1851–2023 and employing the keywords “caffeine intoxication,” “caffeine poisoning,” and “caffeine overdose.”

Results: 216 published individual cases were analyzed. The median caffeine intoxication dose was 12 g (0.05–106 g), and the median serum caffeine concentration was 160 mg/L (15.6–1560 mg/L). The intoxication was deliberate with suicidal intent in 40% of cases, accidental in 22%, and a treatment error in 6%. 21% of the accidental intoxications were in minors. Convulsions and wide-complex tachycardias due to intoxication were associated with a worse outcome, and extracorporeal hemodialysis appears to be a safe and effective way to eliminate caffeine, with a better survival rate even after severe intoxication. Doses of 5–10 g of caffeine can be lethal.

Conclusion: This is the largest analysis of caffeine intoxications ever carried out to date, yet no definitive treatment recommendations can be derived from it. Caffeine elimination by hemodialysis can be considered if the quantity ingested is potentially lethal, or in cases with a severe clinical course.

Cite this as: Uehlein S, Dechant K, Stahl K, Schneider R, Wedemeyer H, Schäfer A: Caffeine intoxication: An analysis of published case reports, 1883–2023. Dtsch Arztebl Int 2025; 122: 523–8. DOI: 10.3238/arztebl.m2025.0113

Caffeine, or 1,3,7-trimethylxanthine, occurs naturally in plants (1, 2, 3) (Box). Caffeine is used for medicinal purposes (4) but also as an ingredient in beverages (5), foodstuffs (6, 7, 8, 9, 10, 11), and nutritional supplements, e.g., pre-workout preparations (12). Tables 1 and 2, respectively, show the average caffeine content of various foods and the health-related aspects (13, 14, 15, 16, 17, 18) of caffeine consumption. Chemically, caffeine is a moderately water-soluble organic substance with low molecular weight and low plasma protein binding (19).

Box

Examples of natural occurrence of caffeine in (crop) plants (1, 2, 3)

Table 1

Average caffeine content of various beverages, foodstuffs, and nutritional supplements (5, 6, 7, 8, 9, 10, 11)

Table 2

Health-related aspects of coffee/caffeine consumption

Intestinal absorption of caffeine takes place within about 45 minutes with almost 99% bioavailability; the plasma peak occurs after about 1 hour. Decomposition is primarily hepatic through the action of the enzyme CYP1A2, with the resulting metabolites then eliminated via the kidneys (1, 13). The metabolites paraxanthine, theobromine, and theophylline are themselves biologically active and contribute to the overall effect of caffeine (13). The half-life is 3–6 hours and is affected by numerous factors (Table 3) (1, 13, 20, 21, 22), particularly the dose of caffeine (21, 23).

Table 3

Pharmacology of caffeine

The pharmacological action (Table 3) (1, 13, 15, 24, 25, 26) and the clinical symptoms are dose-dependent. While intake of around 250 mg of caffeine has been described as leading to euphoria, increased alertness, enhanced concentration, and improved performance, doses of 500 mg have been reported to result in nervousness, anxiety, and palpitations, for example (21, 27, 28).

Symptoms of intoxication can occur starting at about 1–2 g of caffeine or a serum concentration of >15 mg/L. Amounts of 5–10 g, concentrations of 100–200 mg/kg, or serum levels of >80 mg/L are viewed as potentially fatal (1, 14, 29, 30). The thresholds are derived predominantly from case reports.

Caffeine intoxication is defined as the occurrence, after high doses of caffeine, of specific symptoms that cannot be attributed to other physical or mental disorders (31, 32).

The frequency of caffeine intoxication is unknown. Several thousand cases were reported to poison control centers in the USA in 2019, but the actual prevalence is probably higher (33). The symptoms (1, 13, 14, 22, 34, 35, e124) and differential diagnoses of acute intoxication (1, 36) are summarized in Table 4. There are currently no (inter)national guidelines on the treatment of caffeine intoxication.

Table 4

Symptoms and differential diagnoses of acute caffeine intoxication

The European Food Safety Authority (EFSA) issued a caffeine consumption safety assessment in 2015 after several EU member states had expressed concerns about caffeine consumption among the general population, in certain groups, and by individual persons, e.g., physically active adults and consumers of energy drinks (11).

Caffeine in amounts of up to 400 mg/d for healthy adults, 200 mg/d for pregnant and breastfeeding women, and < 2.5 mg/kg body weight for children is considered harmless (11, 37).

Method

This narrative review is based on data from publications between 1851 and 2023 identified by retrieving case reports (search terms: “caffeine intoxication,” “caffeine poisoning,” “caffeine overdose”) from the databases PubMed.gov, Google Scholar, and Semantic Scholar (for details, see the eBox).

eBox

eMethods

Results

The power of this study is significantly limited by several factors. First among these is the lack of randomized prospective data on the treatment of severe caffeine intoxication. The data are therefore derived solely from retrospective case reports and case series, which may be prone to publication bias, e.g., changing publication behavior. The level of evidence regarding treatment options is therefore definitely to be classed as very low. Moreover, the comparability of the data is restricted by the partial lack of information on intoxication, diagnosis, and the patient’s previous history. Furthermore, treatment comparisons are severely hampered by differences in the treatment concepts pursued and by the advances in intensive care medicine over time. Finally, the power of the study is also limited by the fact that the caffeine causing intoxication was ingested in various ways and forms, and the presence of further, unknown substances could not be ruled out.

Intoxication

Overall, the median amount of caffeine causing intoxication in the 142 case reports (

eTable 1

Data from analysis of all case reports found by the literature search described in the Methods section

eTable 1) was 12 g (0.05–106 g), yielding a median serum concentration of 160 mg/L (15.6–1 560 mg/L). The source of intoxication with caffeine-containing substances was injections in 4% of cases, beverages in 5%, powders in 10%, and tablets in 43%; in the remaining 38%, the source was unknown. In one case both tablets and beverages containing caffeine had been ingested. The intoxication occurred with suicidal intent in 40% of cases, accidentally in 22%, as a treatment error in 6%, as child abuse in 1%, and deliberately without suicidal intent or involvement of other persons in 1%; in 29%, the cause was unknown. In view of the inhomogeneous nature of the data, in some cases it is probably uncertain exactly what was involved: accidental intoxication by an unintentional overdose, intentional overdosing with undesired intoxication, or deliberate intoxication by overdosing.

The published case reports were dominated by suicidal and accidental caffeine intoxication (eFigure). The rate of accidental intoxications was slightly higher in men than women (46% versus 35%). The median age of this group was 23 years, and 21% were minors, including a large proportion of infants and young children.

eFigure

Numbers of case reports of caffeine intoxication in 10-year intervals from the 1960s to the 2010s, by cause

The median age of those intending to commit suicide was 25 years, and 55% were women (eTable 2).

eTable 2

Analysis of the 216 cases in 142 case reports during the period 1883–2023 (m = 82, f = 97, n.d. = 37)

eTable 3 shows that caffeine intoxication is a worldwide medical problem. The reported sources of caffeine were caffeine-containing tablets/injected solutions, powders, and beverages.

eTable 3

Occurrence of caffeine intoxication over time, with causes and geographical distribution, in the 216 cases described in 142 reports worldwide in the period 1883 to 2023

Details of cases of accidental and deliberate intoxication can be found in eTable 4. All analyses below refer explicitly to the 134 cases in which the intoxicated person was found alive.

eTable 4

Details on accidental and deliberate caffeine intoxication

Symptoms

Data on initial (pre)clinical symptoms and/or laboratory test results were present in 89 cases. The most frequent clinical presentations were agitation (24% of patients), anxiety (16%), and tremor (14%), while 30% reported nausea and 10% experienced palpitations. Moreover, recurrent vomiting was found in 60% of cases, tachycardia in 87%, and tachypnea in 36%. Advanced intoxication was accompanied by metabolic acidosis (25%), lactatemia (23%), hypokalemia (33%), and less frequently by respiratory alkalosis (3%), hypophosphatemia (8%), hyperglycemia (8%), and rhabdomyolysis (10%). Later in the course, 15% of the 89 persons affected experienced convulsions. More than 50% of the patients with tonic–clonic seizures also had hemodynamically relevant cardiac arrhythmia, in some cases refractory. Altogether, 18% of the 134 patients had convulsions, 13% ventricular tachycardia, 14% ventricular fibrillation, 2% torsades, and 5% pulseless electrical activity.

A closer look at these severe symptoms reveals that the serum concentrations tended to be lower in narrow-complex tachycardia than in wide-complex tachycardia or convulsions. Patients with convulsions/wide-complex tachycardia had higher caffeine doses/serum concentrations than those without (eTable 5). Classification into different types of convulsions was impossible due to lacking or imprecise data.

eTable 5

Reported caffeine dose/serum concentration in cases of intoxication with cardiac arrhythmia and convulsions

Examination of the distribution of intoxication doses/serum concentrations among those with narrow-/wide-complex tachycardia as well as convulsions reveals that widely varying clinical manifestations can occur in persons with similar caffeine doses and serum concentrations. Cases of narrow-complex tachycardia were described with caffeine doses from 0.05 g and caffeine serum concentrations from 46 mg/L; convulsions from 0.5 g and 29 mg/L respectively; and wide-complex tachycardia from 2 g and 19 mg/L. More rarely, patients had neurological symptoms, such as decreased vigilance (11%), myoclonus (7%), disorientation (5%), vertigo (3), hallucinations (2%), and amyosthenia (1%).

Clinical course

The type and duration of intoxication as well as the (pre)clinical course were extremely variable in the case reports analyzed.

Intrahospital diagnosis

Among the 134 cases, patients with tablet intoxication had a median serum concentration of 141 mg/L and mortality of 27%. The figures for powder intoxication were 19 mg/L and 12%. In the cases with caffeine from an unknown source, the median serum concentration was 195 mg/L and the mortality rate for the cases analyzed was 15%. Data on caffeine dose were missing in 45 cases (33.6%), on the highest measured serum concentration in 43 cases (32.1%), and on both in 10 cases (7.5%).

Treatment and prognosis

Contact with a poison control center was reported in 3.7% of cases. To prevent further caffeine resorption, activated charcoal was administered in 21.6% of cases and stomach pumping was carried out in 11.2%, usually within 2 hours after ingestion. In three cases (2.2%) from the 1980s, ipecacuanha syrup was given.

Persons in whom wide-complex tachycardia occurred without accompanying convulsions survived in 83% of the cases analyzed. For those who had convulsions unaccompanied by cardiac arrhythmia, the survival rate was only 44%. Combined cardiac arrhythmia and convulsions were survived by a surprising 86.7% of patients; this may have been associated with more intensive treatment or may be explained by publication bias. Supraventricular cardiac arrhythmia was treated primarily with beta blockers, less often with digoxin, verapamil, adenosine, amiodarone, or benzodiazepines. Amiodarone and lidocaine were the drugs used primarily to treat ventricular cardiac arrhythmia. Some 6.7% of patients underwent extracorporeal membrane oxygenation (ECMO) due to refractory cardiac arrhythmia. The survival rate in the small number of cases with ECMO was 78%.

Among the 28 persons found alive, the stated causes of death were 5 × cardiac/cardiocirculatory arrest, 3 × asystole, 2 × ventricular fibrillation, 4 × shock or cardiac/cardiocirculatory failure, 3 × unsuccessful cardiopulmonary resuscitation, 1 × pneumonia, 1 × pulmonary edema, and 1 × cerebral edema with incarceration. In eight cases the cause of death was not specified.

In six cases a 20% lipid solution was infused to stabilize the hemodynamics and heartbeat. Five of these six persons had first been given active charcoal or had their stomach pumped, and the sixth had been treated with high-dose insulin. The assumed reason for the successful outcome of lipid emulsion treatment is caffeine dose reduction in the heart and brain. The precise mechanism is still unknown, but the most likely candidates are thought to be the (scavenging) shuttle effect and the lipid sink theory (e57).

Extracorporeal blood cleansing was carried out in 28% of cases, being used in 38% of patients with convulsions, 33% of those with narrow-complex tachycardia, and 54% of those with wide-complex tachycardia. It therefore seems that wide-complex tachycardia more frequently led to intensification of treatment by means of eliminatory procedures. The stated indications were a potentially fatal dose of caffeine, acute kidney injury, rhabdomyolysis, acidosis, electrolyte imbalance, volume overload, neurological factors, and (refractory) instability of hemodynamics and cardiac rhythm. Amelioration of the symptoms and improvements in metabolism, hemodynamics, and stability of heart rhythm were described, beginning about 0.5 to 4 hours after the start of the blood cleansing procedure.

The highest survived caffeine serum concentration was 368 mg/L without and 574 mg/L with blood cleansing. Compared with those without blood cleansing, patients with blood cleansing had a higher median caffeine dose (29 g versus 6 g), a higher median initial serum concentration (185 mg/L versus 121 mg/L), and a higher survival rate (95% versus 73%). According to the case reports, survivors with blood cleansing had higher caffeine doses/initial caffeine serum concentration than those without blood cleansing. There were no indications of potential differences with regard to intoxication and clinical manifestations between those with blood cleansing who survived and those without blood cleansing who died.

The intoxication dose was less often stated or known in those without blood cleansing who died than in survivors with/without blood cleansing (39% versus 67%/86%, eTable 6). There was no comparison of the various blood cleansing methods due to the low case numbers and the lack of adjustability of the data by disease severity. A synopsis of all treatment procedures can be found in eTable 7.

eTable 6

Reported intoxication dose/serum concentration in those who did and did not survive, with and without blood cleansing

eTable 7

Synopsis of the symptomatic and causal measures and procedures used in the cases reported

According to the case reports, survival can be achieved by means of timely antiresorptive and eliminatory therapy and symptomatic treatment despite high intoxication doses of up to 100 g and initial serum concentrations as high as 574 mg/L. In individual cases, however, patients died in spite of these measures.

Discussion

Caffeine intoxication—especially with suicidal intent—can be an extremely challenging clinical entity, an entity for which awareness of the problem, preventive measures, as well as medical structures for diagnosis and treatment are still lacking. The latter is due in part to the lack of reliable data and the absence of recommendations and guidelines.

The published systematic reviews concern themselves primarily with pharmacokinetics and the health-related consequences of caffeine consumption (13, 14, 20, 21, 22, 37, 38); only individual case reports and case series are available on the diagnosis and treatment of acute intoxication, particularly with (supra)lethal doses of caffeine.

Overall, the available data are very limited and also extremely heterogeneous, because only multiple individual case reports have been published. However, we were able to show that the clinical symptoms are particularly relevant for estimation of the severity of intoxication. Convulsions and wide-complex tachycardia are associated with poorer outcome and can occasionally even occur at low double-digit serum concentrations. Moreover, our analysis suggests that antiresorptive measures may be associated with a survival advantage and that extracorporeal blood cleansing represents an established, safe, and efficient method for caffeine elimination, with a high survival rate even in cases of severe intoxication. This review is the largest analysis to date of case reports on acute caffeine intoxication for evaluation of treatment.

Diagnosis and treatment were often hampered by difficulty in obtaining the patient’s history and a lack of means to determine the caffeine concentration. A potential solution to this problem has been provided by Morita et al., who showed in a group of 25 previously healthy persons with known caffeine intoxication that the serum concentration of caffeine could be estimated by semiquantitative demonstration of glucose and ketone bodies on urine test strips (39).

We attempted to correlate the occurrence of cardiac arrhythmia and convulsions with the dose and serum concentration of caffeine. While narrow-complex tachycardia occurred at a median concentration of 99 mg/L, the corresponding figures for convulsions and wide-complex tachycardia were 205 mg/L and 248 mg/L respectively (eTable 5). It was not possible to analyze the extent to which errors in measurement (technique), previous illness, combined intoxications, or features of the course taken by serum concentration affected disease progression and treatment response. It must also be borne in mind that the maximum concentration measured does not necessarily represent peak serum caffeine. To date, caffeine resorption studies have not been conducted with (supra)lethal doses. The data on resorption come exclusively from case reports. It is conceivable that the intoxication itself influences further resorption, e.g., by retropulsive peristalsis.

Because convulsions and wide-complex tachycardia are associated with poorer outcome (40, e143), it is advisable to prevent the intoxication progressing to this point or, failing that, to take measures to eliminate the caffeine. Intralipid administration and blood cleansing have proved to be the most effective ways of eliminating high concentrations. With regard to the intravenous infusion of lipid emulsions, it should be noted that these can falsify laboratory test results (e144) and affect clearance via hemodialysis filters (e145).

The prevalence, incidence, and mortality of intoxication with caffeine, alone or in combination with other substances, in the general population remain to be determined. On the basis of the case reports and the characteristics of caffeine, possible risk groups are very young persons (neonates, infants, children), athletes (pre-workout supplements), persons who are under high pressure at work, need to concentrate, or suffer from lack of sleep (military personnel, students), persons with mental illness (e.g., depression), and those who attend events where there is an elevated risk of combined intoxication (e.g., clubbers). Persons who consume energy drinks, particularly those with high caffeine content (e146), may also be at risk.

Conclusion

Increasing numbers of case reports on caffeine intoxication are being published, with particular reference to suicidal and accidental intoxications and intoxication of unknown cause. To date, no evidence-based treatment guidelines exist.

As well as symptomatic treatment and antiresorptive measures, eliminatory procedures should be considered in patients with potentially fatal caffeine intoxication doses or serum concentrations, especially in those with aggravated clinical manifestations such as convulsions and clinically relevant cardiac arrhythmia.

Funding

The authors received no financial support for this study.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 16 December 2024, revised version received on 17 June 2025

Translated from the original German by David Roseveare

Corresponding author
Dr. med. Sabrina Uehlein

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